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Form
Approved – OMB No. 0505-0027
Expiration
Date: __/__/20__
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Certification
Regarding Debarment, Suspension,
Ineligibility and Voluntary Exclusion
Lower
Tier Covered Transactions
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The
following statement is made in accordance with the Privacy Act of
1974 (5 U.S.C. § 552a, as amended). This certification
is required by the regulations implementing Executive Order 12549,
Debarment and Suspension, and 2 C.F.R. §§ 180.300,
180.355, Participants' responsibilities. The regulations were
amended and published on August 31, 2005, in 70 Fed. Reg.
51865-51880. Copies of the regulations may be obtained by
contacting the Department of Agriculture agency offering the
proposed covered transaction.
According
to the Paperwork Reduction Act of 1995 an agency may not conduct
or sponsor, and a person is not required to respond to a
collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information
collection is 0505-0027. The time required to complete this
information collection is estimated to average 15 minutes per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. The
provisions of appropriate criminal and civil fraud privacy, and
other statutes may be applicable to the information provided.
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(Read
Instructions On Page Two Before Completing Certification)
The
prospective lower tier participant certifies, by submission of
this proposal, that neither it nor its principals is presently
debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from participation in this transaction by
any Federal department or agency;
Where
the prospective lower tier participant is unable to certify to
any of the statements in this certification, such prospective
participant shall attach an explanation to this proposal.
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ORGANIZATION
NAME
PR/AWARD NUMBER OR PROJECT NAME
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NAME(S)
AND TITLE(S) OF AUTHORIZED REPRESENTATIVE(S)
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SIGNATURE(S)
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DATE
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In
accordance with Federal civil rights law and U.S. Department of
Agriculture (USDA) civil rights regulations and policies, the USDA,
its Agencies, offices, and employees, and institutions participating
in or administering USDA programs are prohibited from discriminating
based on race, color, national origin, religion, sex, gender identity
(including gender expression), sexual orientation, disability, age,
marital status, family/parental status, income derived from a public
assistance program, political beliefs, or reprisal or retaliation for
prior civil rights activity, in any program or activity conducted or
funded by USDA (not all bases apply to all programs). Remedies and
complaint filing deadlines vary by program or incident.
Persons
with disabilities who require alternative means of communication for
program information (e.g., Braille, large print, audiotape, American
Sign Language, etc.) should contact the responsible Agency or USDA's
TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA
through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than
English.
To
file a program discrimination complaint, complete the USDA Program
Discrimination Complaint Form, AD-3027, found online at How
to File a Program Discrimination Complaint and at any USDA office
or write a letter addressed to USDA and provide in the letter all of
the information requested in the form. To request a copy of the
complaint form, call (866) 632-9992. Submit your completed form or
letter to USDA by: (1) mail: U.S. Department of Agriculture, Office
of the Assistant Secretary for Civil Rights, 1400 Independence
Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442.
Instructions
for
Certification
By
signing and submitting this form, the prospective lower tier
participant is providing the certification set out on page 1 in
accordance with these instructions.
The
certification in this clause is a material representation of fact
upon which reliance was placed when this transaction was entered
into. If it is later determined that the prospective lower tier
participant knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal Government,
the department or agency with which this transaction originated
may pursue available remedies, including suspension or debarment.
The
prospective lower tier participant shall provide immediate
written notice to the person(s) to which this proposal is
submitted if at any time the prospective lower tier participant
learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
The
terms "covered transaction," "debarred,"
"suspended," "ineligible," "lower tier
covered transaction," "participant," "person,"
"primary covered transaction," "principal,"
"proposal," and "voluntarily excluded," as
used in this clause, have the meanings set out in the Definitions
and Coverage sections of the rules implementing Executive Order
12549, at 2 C.F.R. Parts 180 and 417. You may contact the
department or agency to which this proposal is being submitted
for assistance in obtaining a copy of those regulations.
The
prospective lower tier participant agrees by submitting this form
that, should the proposed covered transaction be entered into, it
shall not knowingly enter into any lower tier covered transaction
with a person who is debarred, suspended, declared ineligible, or
voluntarily excluded from participation in this covered
transaction, unless authorized by the department or agency with
which this transaction originated.
The
prospective lower tier participant further agrees by submitting
this form that it will include this clause titled "Certification
Regarding Debarment, Suspension, Ineligibility and Voluntary
Exclusion - Lower Tier Covered Transactions," without
modification, in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
A
participant in a covered transaction may rely upon a
certification of a prospective participant in a lower tier
covered transaction that is not debarred, suspended, ineligible,
or voluntarily excluded from the covered transaction, unless it
knows that the certification is erroneous. A participant may
decide the method and frequency by which it determines the
eligibility of its principals. Each participant may, but is not
required to, check the System for Award Management (SAM)
database.
Nothing
contained in the foregoing shall be construed to require
establishment of a system of records in order to render in good
faith the certification required by this clause. The knowledge
and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary
course of business dealings.
Except
for transactions authorized under paragraph (5) of these
instructions, if a participant in a covered transaction knowingly
enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies
available to the Federal Government, the department or agency
with which this transaction originated may pursue available
remedies, including suspension and/or debarment.
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Form
AD-1048
(REV
12/18)
Page
2 of 2
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | This form is available electronically |
Author | erica.robinson |
File Modified | 0000-00-00 |
File Created | 2021-01-15 |